The Systems Change Team coordinates a series of systems change projects alongside partners, those with lived experience of multiple and complex needs, Fulfilling Lives’ volunteers and staff across the six agreed thematic areas.

T1: Inequalities in healthcare  

T2: Domestic Abuse Pathways

T3: Criminal Justice System - Repeat Offending 

T4: Treatment Pathways for Co-existing Conditions

T5: Temporary accommodation

T6: Repeat Removals of children into the care system


T1 - Health Inequalities

Restricted access to healthcare is a strong and consistent theme in our casework. Client case studies evidence a stark and disturbing picture of the very real health inequalities experienced by people with multiple and complex needs.

Client data shows that 84% (43 of a total 51) of current clients have a physical health problem or problems. Many have a combination of long-term chronic conditions such as liver cirrhosis, hepatitis C, diabetes and circulatory diseases. The female clients we work with have more complex and chronic conditions compared to men. A number of factors contribute to this, including the impact of domestic abuse and violence, as well as the stress on the body from rough sleeping.

The average life expectancy of homeless people is low – for men this is 47 years of age, for women this is 43 years of age. Fulfilling Lives (FL) has worked with 94 clients to date. Ten clients have died, eight of whom were female clients (their average age was 41 years at the time of their death).

Our Commitments for Change:

Our commitments relate to key pressure points for clients with MCN within the healthcare system:

  1. People with MCN will have improved access to, and coordination of, primary care to better address their needs
  2. All clients with MCN who are placed on the SPS will have an annual review in line with current guidelines
  3. The triage system in A&E will be able to identify people with MCN and to assess potential risks and the need for follow-up care and support when they are discharged
  4. Workers who support clients with MCN will be informed and empowered to use official systems to challenge and escalate unsatisfactory responses and care
  5. Hospital discharge protocols for MCN clients will be fit for purpose and consistently implemented


T2 - Domestic Abuse and Complex Needs

Domestic abuse and violence is a very common experience for this client group. In a snapshot in December 2018, 93% of the women on our caseload had experienced domestic abuse (25 out of 27 women) and at the time of the snapshot 13 of the 25 women were currently experiencing domestic abuse. This prevalence has been consistent throughout the lifetime of the project.

Of these 25 women, 76% were homeless (rough sleeping/in temporary accommodation/sofa surfing/in hostels), 96% had both substance misuse and mental health needs when we began working with them, 88% had histories of offending, and 72% had disabilities.

Our Commitments for Change:
  1. Women with MCN who present to the local authority as homeless and experiencing domestic abuse will receive a trauma informed response which is appropriate to their needs, and creative safety planning – including access to appropriate accommodation
  2. Women with MCN who are experiencing high risk domestic abuse will be offered one to one support from a specialist domestic abuse service
  3. Women with MCN who are heard at MARAC will have a robust multi-agency safety plan (including housing, adult social care, substance misuse, mental health, police, IDVA) that takes account of safeguarding issues and includes shared accountability and clear actions with deadlines
  4. The staff in non-specialist services supporting women with MCN will be equipped and trained to better respond to domestic abuse


T3 - Criminal Justice System – Repeat Offending

Our statistics show that people with multiple and complex needs are overrepresented in the criminal justice system. Of the 94 people we have worked with up to December 2018, 25 clients (27%) have been in prison. This compares to 0.18% of the general population. In our current caseload of 52 clients, 20 people have patterns of repeat offending; all have identified mental health problems and are alcohol and/or drug dependent. This client group are some of the most complex and disadvantaged and remain on our caseload the longest - of these 20 cases (eleven men and nine women) 50% have been on our caseload for three years or more.

These individuals are engaged in repeat cycles of acquisitive crime, such as shoplifting and theft; their offending is often driven by active addiction. They receive short custodial sentences and are regularly released as street homeless where the chaotic nature of their lives leads to breaching license conditions and being recalled to prison after only a short time in the community. Those receiving community sentences frequently breach probation orders, again due to the lack of stability in their lives, resulting in them being recalled to prison. Clients quickly get caught in cyclical offending and the revolving door between prison and the community.

There are few or no steady periods of stability (either in prison or in the community) in which the person can address their addiction, their mental health or their homelessness in order to break the cycle; instead, the cycle exacerbates and perpetuates these problems. Work is focused on immediate crisis and risk-led interventions, rather than on planned or preventative work to support individuals to break the cycle and reduce reoffending.

Our Commitments for Change:
  1. For no clients with multiple and complex needs to be released as street homeless
  2. For no clients with multiple and complex needs to be released from prison on a Friday
  3. For clients with multiple and complex needs to have a named CRC / Probation worker to coordinate their release and resettlement planning
  4. For clients with multiple and complex needs to receive multi-agency case coordination of their support in the community
  5. For women with multiple and complex needs to have access to a gender-informed package of support


T4 - Treatment Pathways for Coexisting Conditions

Substance misuse and mental ill health are the most commonly experienced problems for people on the Fulfilling Lives caseload (94% and 96% of the project’s caseload respectively). There is a high degree of overlap between the two conditions, with 90% of beneficiaries experiencing both. This is consistent across the national Fulfilling Lives programme. There is a corresponding prevalence of complex trauma amongst beneficiaries; much of this linked to Adverse Childhood Experiences.

Current clinical pathways often require an individual to address their substance use before mental health treatment can be provided. Ongoing substance use can result in an assessment not commencing or even being attempted.

This is despite current NICE (National Institute of Health and Care Excellence) and PHE (Public Health England) best practice guidance being clear that a ‘no wrong door’ principle should apply, with no one being turned away from services because of co-occurring mental health and substance misuse conditions.

The substance misuse treatment system is difficult to navigate for people with the most complex needs, in particular when their mental health needs are considerable; many clients have needs that are undiagnosed or untreated. For example, the focus on group work can be a barrier as can the requirements to demonstrate consistent stability and motivation.

We aim to focus the project’s work on improving access, engagement and successful outcomes in substance misuse treatment for people with multiple and complex needs by looking at the following two areas of this complex issue:

  • Pre-treatment psychological support to address complex trauma so that clients can access substance misuse treatment effectively
  • In-treatment support for those with dual needs to engage with, and succeed in, all stages of substance misuse treatment by having their mental health needs adequately supported throughout
Our Commitments for Change:
  1. For all clients with complex trauma presentations to have access to psychological support to help prepare for accessing formal treatment
  2. For mental health support to run in parallel at all stages of substance misuse treatment i.e. access, assessment, community substance misuse services, detox and residential rehab


T5 - Unsupported Temporary Accommodation

The housing shortage is particularly acute in the South East of England. The increasing demand and competition for private rented accommodation, as well as landlords increasingly choosing not to accept tenants on Universal Credit, have contributed to significantly reduced housing options for people with complex needs; there is a crisis of supply.

This crisis of supply, together with growing numbers of people becoming homeless, has resulted in increased pressure on local authorities to source and provide temporary accommodation.

Higher numbers of people with multiple and complex needs are being placed in unsupported temporary accommodation, including out of area placements, and are remaining in this accommodation for longer.

Our Commitments for Change:
  1. To establish acceptable minimum standards of training and quality for TA providers, in order for local authorities to use them to provide temporary accommodation for people with MCN
  2. To develop a tool for Housing Options teams to identify people with MCN
  3. To agree a protocol whereby MCN clients who are being assessed for TA will have an identified lead professional/support worker to coordinate a package of support i.e. for no MCN client to be without a tangible and achievable package of support in place
  4. For Housing Options teams to routinely share relevant information with TA providers at the time of placement, including: clients’ support agencies and professionals, support needs and associated risks
  5. For people with MCN not to be placed out of area unless they have specifically requested it. If, in exceptional circumstances, MCN clients are placed out of area, for them to always be prioritised for a placement back in their local area


T6 - Repeat Removals of Children Into the Care System

Every Local Authority in Britain has experience of working with women who have multiple children removed from them and placed into the care system. Many of these women face multiple disadvantages and have complex histories that include; being in the care system themselves, sexual abuse, domestic abuse and violence, substance misuse, learning disabilities and mental health conditions. They are also significantly more likely to require interventions from public services throughout their lives.

After a child has been removed into care, women are often left without support at a time when they are especially vulnerable. Due to the complexity of the issues involved, women often become pregnant again and this damaging cycle is repeated, sometimes multiple times.

Fulfilling Lives is not seeking to challenge decisions to remove children, but to identify and highlight opportunities for more supportive interventions to be considered and for the cycle of repeat removals to be interrupted.

Our Commitments for Change:
  1. For women with multiple and complex needs to not suffer stigmatising practice (e.g. from antenatal and post-natal health care providers, courts, police, GP and social services
  2. For all women with multiple and complex needs going through child protection or care proceedings to be offered access to independent advocacy, with the aim of helping women to understand each stage of the process, including what is going to happen next
  3. For all women with multiple and complex needs who have a child permanently removed from their care to have access to therapeutic aftercare
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